Motti Ratmansky

Trigger Point Needling: Techniques and Outcome

In this review we provide the updates on last years’ advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling.

The Effects of Acupuncture on Cerebral Blood Flow in Post-Stroke Patients: A Randomized Controlled Trial.

BACKGROUND/OBJECTIVE Stroke is a major cause of disability and death in the Western world. Studies have shown a direct relationship between specific mental and motor activity and changes in cerebral blood flow. Acupuncture is often used in post-stroke patients, but there is a lack of sham-controlled studies evaluating the effects of acupuncture on cerebral blood flow following a stroke. This pilot concept-assessment study sought to evaluate the effects of true acupuncture on cerebral blood flow velocity compared with sham acupuncture and lay a foundation for future work in this field. METHODS Seventeen inpatients (age range, 44-79 years) 1-3 months post-stroke were allocated to acupuncture at true acupuncture (TA) points or at sham acupuncture (SA) points. The treatment was 20 minutes long. Transcranial Doppler ultrasonography was used to measure mean flow velocity (MFV) and peak flow velocity (PFV) at both healthy and damaged hemispheres before (T0), in the middle of (T15), and 5 minutes after (T25) treatment. Blood pressure was measured at T0 and T25. RESULTS A statistically significant (p < 0.04) MFV increase in both hemispheres was found during and after TA; this increase was higher than that seen with SA (p < 0.035). Acupuncture had no significant effect on PFV. Systolic blood pressure significantly decreased after acupuncture (p < 0.005) in a similar manner for both TA and SA. National Institutes of Health Stroke Scale score was negatively correlated with MFV at T15 (r = -0.825; p < 0.05). CONCLUSION This pilot study showed a significant influence on cerebral blood flow velocity by TA. This study lays a foundation for larger-scale studies that may prove acupuncture to be a useful tool for cerebral blood flow enhancement during post-stroke rehabilitation.

Trends in Physical Medicine and Rehabilitation Publications Over the Past 16 Years

OBJECTIVES To test the hypothesis that the number of publications in the field of physical medicine and rehabilitation (PMR) has increased over the last 16 years in a linear fashion, and to compare the trends in publication between the pediatric and adult literature. DESIGN We evaluated all MEDLINE articles from January 1, 1998, to December 31, 2013, using Medical Subject Headings categories of rehabilitation. An age filter separated adult and pediatric articles. We divided articles into those with a low level of scientific evidence such as letters and editorials, and those with a high level of evidence such as controlled trials and meta-analyses. We used regression analysis to evaluate the effect of the year of publication on the number of publications of each type. SETTING Not applicable. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS MEDLINE reported a total of 98,501 adult publications and 30,895 pediatric publications during the evaluated period. There was a significant linear increase in the total number of publications in adult and pediatric rehabilitation publications with multiplication factors of 3.3 and 2.9, respectively. Importantly, publications with a high level of evidence showed larger multiplication factors compared with those with a low level of evidence (5.5 and 5.1 vs 2.1 and 2.0) for the adult and pediatric literature. CONCLUSIONS The number of publications in the PMR field, especially those with a high level of scientific evidence, has increased linearly over the years, reflecting the rapid evolution of both adult and pediatric PMR.

A RANDOMIzeD CONTROLLeD STUDy OF SegMeNTAL NeUROMyOTHeRAPy FOR POST-STROke HeMIPLegIC SHOULDeR PAIN

OBJECTIVE To assess the effectiveness of segmental neuromyotherapy combined with standard hospital therapy relative to standard therapy alone in patients with hemiplegic shoulder pain. DESIGN Randomized controlled trial. PATIENTS A total of 24 patients with positive Neers and hand-behind-neck tests received standard therapy for shoulder pain. Half of them received additional segmental neuromyotherapy. METHODS Pain severity (visual analogue scale), upper-limb function (Fugl-Meyer arm score), and spasticity (Ashworth scale) were evaluated at 2 days (T1) and 1 day (T2) pre-treatment, in the middle (T3) and at the end (T4) of 4 weeks treatment, and 2 months post-treatment (T5). RESULTS The treatment group showed significant advantage compared with the Control group in Fugl-Meyer scores at T4 (p = 0.014) and T5 (p = 0.0078) compared with initial values. Significant advantage was also shown in the Neers test at T4 (p = 0.014), with borderline significance at T5 (p = 0.072). A larger decrease in pain scores reported by the treatment group at T5 (p = 0.068) may have been biased by higher rates of spatial neglect in this group. CONCLUSION Segmental neuromyotherapy added to standard therapy provides an advantage in pain relief and overall arm function in patients with hemiplegic shoulder pain.

Effect of kinesio tape application on hemiplegic shoulder pain and motor ability: a pilot study.

The aim of our single-group pre–post design pilot study was to evaluate the short-term effect of kinesio taping (KT) application on pain and motor ability of hemiplegic shoulder pain (HSP) patients. Eleven poststroke patients with HSP hospitalized in the Department of Neurology C, Loewenstein Rehabilitation Hospital, Raanana, Israel, received a KT application in addition to their usual rehabilitation protocol. KT, consisting of one to three strips according to a predefined algorithm, was applied to the painful shoulder region. A 10 cm Visual Analog Scale of shoulder pain at rest and at arm movement, active and passive pain-free abduction range of motion, Box & Blocks, and Fugl-Meyer upper extremity motor assessment were performed before treatment and 24 h after wearing the KT. After applying the KT, there was no significant change in any variables. Short-term KT application, used in our study, produced no change in shoulder pain, range of motion, or ability of upper limb in HSP patients. Additional studies should evaluate the effect of long-term application and different types of KT applications on HSP.

Position Statement of the Israeli Society for Musculoskeletal Medicine on Intramuscular Stimulation for Myofascial Pain Syndrome—A Delphi Process

To develop consensus on a position paper on the use of intramuscular stimulation (IMS) for the treatment of myofascial pain syndrome (MPS) by physicians in Israel.

Deficient pain modulation in patients with a chronic hemiplegic shoulder pain

Hemiplegic shoulder pain (HSP) following stroke significantly affects the individuals function and quality of life. The mechanism of HSP is not clearly understood; hence, it is unclear why HSP resolves spontaneously or following routine care in some patients, while in others it becomes persistent. The aim was therefore to study whether HSP is associated with deficient pain modulation.

The local and referred pain patterns of the longus colli muscle

The longus colli muscle is a neck flexor believed to play an important role in pain originating in the neck region, including pain resulting from whiplash injuries. Despite the clinical importance attributed to it, the pain referral pattern of the longus colli has previously been described only in a small cohort of subjects. Here, we aim to delineate the pain referral pattern of the longus colli muscle. Thirty-five healthy volunteers underwent deep massage of the longus colli followed by dry needling of the muscle. The subjects depicted the distribution of the pain they experienced on a blank manikin. Their drawings were digitized and used to produce pain pattern histogram maps. The pain referral pattern during deep massage and needling of the longus colli was primarily local, with referral to the ipsilateral ear and lateral to the ipsilateral eye. Some subjects reported pain on the contralateral side of the neck.